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Employment Application

INSTRUCTIONS: Please complete all portions of this employment application to be considered for employment. If you require accommodation during the employment process, including assistance in the completion of this employment application, please let us know. We are an equal opportunity employer. We do not discriminate on the basis of age, race, sex, religion, color, national origin, ancestry, marital status, disability, sexual orientation, arrest and court record or any other protected category recognized by state and federal laws. This employment application is valid for a three month period after submission to the credit union and only for the desired position. Consideration for employment after the three-month period requires completion and submission of a new application.

* indicates a required field.

PERSONAL INFORMATION

*Last Name:

*First Name:

*Social Security Number:

Social Security Number SSN Part 1 - Social Security Number SSN Part 2 - Social Security Number SSN Part 3

*Can you upon employment, submit verification of your legal right to work in the United States and proof of age?

YesNo

*Have you ever been convicted of a crime or entered a pretrial diversion program to avoid a conviction?

YesNo

If yes, please list:

DESIRED EMPLOYMENT

*Position applying for:

*Desired Time:

Full-timePart-time

*Date you can start:

*Pay expected:

*Have you applied for work with us before?

YesNo

Where?

When?

*Have you worked for us before?

YesNo

Where?

When?

*Apart from religious services, will you be able to work all other times?

YesNo

(If hired, you will be required to perform work as required by the credit union.)

*Who referred you to us?

Relative

Employment Agency

Newspaper Ad

Friend

State Employment Office

College Placement Service

Walk in

Other

EDUCATIONAL BACKGROUND

*High School:

Major:

Years There:

Graduated?

YesNo

Certificate:

DiplomaGED

Technical School:

Major:

Years Spent:

Graduated?

YesNo

Degree/Diploma:

College:

Major:

Years Spent:

Graduated?

YesNo

Degree/Diploma:

College:

Major:

Years Spent:

Graduated?

YesNo

Degree/Diploma:

Graduate School:

Major:

Years Spent:

Graduated?

YesNo

Degree/Diploma:

Other:

Major:

Years Spent:

Graduated?

YesNo

Degree/Diploma:

EMPLOYMENT

Starting with your present or last job, provide complete employment history for the last 10 years. You must answer all questions and this employment history must be completed even if you submit a resume.

1. Name of Employer:

Phone Number:

Phone Number Area Code( )
Phone Number Part 1 -
Phone Number Part 2Phone Number Extensionext:

Employer Address:

Employer Address Street

Employer Address City

Employer Address State

Employer Address Zip Code

Beginning Date of Employment:

Ending Date of Employment:

Position Title and Duties:

Reason for leaving

Supervisor’s Name

May we contact this employer?

YesNo

If no, explain:

2. Name of Employer:

Phone Number:

Phone Number Area Code( )
Phone Number Part 1 -
Phone Number Part 2Phone Number Extensionext:

Employer Address:

Employer Address Street

Employer Address City

Employer Address State

Employer Address Zip Code

Beginning Date of Employment:

Ending Date of Employment:

Position Title and Duties:

Reason for leaving

Supervisor’s Name

May we contact this employer?

YesNo

If no, explain:

3. Name of Employer:

Phone Number:

Phone Number Area Code( )
Phone Number Part 1 -
Phone Number Part 2Phone Number Extensionext:

Employer Address:

Employer Address Street

Employer Address City

Employer Address State

Employer Address Zip Code

Beginning Date of Employment:

Ending Date of Employment:

Position Title and Duties:

Reason for leaving

Supervisor’s Name

May we contact this employer?

YesNo

If no, explain:

REFERENCES

Please provide the names of three persons you are not related to, you have known at least one year and whom we may contact.

*Name:

*Address:

*Phone:

Phone Area Code( )
Phone Part 1 -
Phone Part 2Phone Extensionext:

*Yrs. known:

*Name:

*Address:

*Phone:

Phone Area Code( )
Phone Part 1 -
Phone Part 2Phone Extensionext:

*Yrs. known:

*Name:

*Address:

*Phone:

Phone Area Code( )
Phone Part 1 -
Phone Part 2Phone Extensionext:

*Yrs. known:

JOB SKILLS, QUALIFICATIONS AND EMPLOYMENT GAPS

*Summarize your job skills, training and/or study that are relevant for the desired position. Also, explain any periods that you were not working.

CERTIFICATION

PLEASE READ CAREFULLY BEFORE SIGNING

I certify that the information in this application is true, correct, and complete. I understand that any false or misleading statements or omissions made in this application or interview(s) are grounds for disqualification from further consideration or for dismissal from employment, regardless of when and how discovered.

I understand that MY EMPLOYMENT IS AT-WILL AND CAN BE TERMINATED AT ANY TIME AND FOR ANY REASON WITH OR WITHOUT ADVANCE NOTICE.

I understand and agree that only the President/CEO of Your Neighborhood Credit Union has any authority to enter into any agreement to employ me for any specified period of time or to modify terms and conditions of my employment. I agree that such an agreement must be in writing and signed by the President/CEO, and I will not rely upon any other representations regardless of the source.

I understand and agree that Your Neighborhood Credit Union may make a full and complete investigation of my personal, financial or employment history, and authorize any former employer, person, firm, corporation, school, government agency, or other entity to provide Your Neighborhood Credit Union with any information (including fact or opinion) they may have regarding me. In consideration of Your Neighborhood Credit Union review of this application, I release Your Neighborhood Credit Union and all providers of any information from any liability which may arise as a result of furnishing and receiving this information. I understand and agree any employment offer or continued employment shall be conditioned on the receipt of satisfactory references as determined by Your Neighborhood Credit Union. If employed by Your Neighborhood Credit Union, I further authorize Your Neighborhood Credit Union to provide truthful information (including fact or opinion) regarding my employment to any potential or future employer and release and waive any claims against Your Neighborhood Credit Union for truthfully communicating any such information to a potential or future employer.

I understand and authorize Your Neighborhood Credit Union to obtain a consumer credit report as part of the pre-employment background investigation. If hired, this authorization shall remain on file and shall serve as an ongoing authorization for Your Neighborhood Credit Union to obtain consumer credit reports at any time during my employment period.

I understand, agree and voluntarily consent to be tested for evidence of the presence of alcohol and/or drugs in my body through the analysis of my urine, breath (if permitted by law) or blood in the manner specified in the Employee Substance Abuse Policy. I further consent to the release of the results of the substance abuse tests by the medical laboratory facility to the Medical Review Officer designated by Your Neighborhood Credit Union (the “Credit Union”). I further consent to the release of verified positive test results for substance abuse by the Medical Review Officer for the Credit Union. I also understand that only those job applicants who have been selected to fill job openings will be subject to substance abuse testing. If a substance abuse test is required, a negative substance abuse test result will be a condition of actual hire. I further understand, agree and voluntarily consent to submit to random substance abuse testing that may be required during the term of my employment.

I understand and agree that Your Neighborhood Credit Union may inquire into and consider any criminal conviction record that I may have, which bears a rational relationship to the duties and responsibilities of the position for which I am applying, in accordance with state and federal laws. In that regard, I understand that Your Neighborhood Credit Union cannot hire or retain in employment a person who has been convicted of any criminal offense involving dishonesty or breach of trust, or has agreed to enter into a pretrial diversion or similar program in connection with a prosecution for such offense, without the prior written consent of the National Credit Union Board (NCUA). I also understand and agree that being eligible for full bond and loss insurance coverage (without increased premiums or deductibles or other modifications or exceptions) is a condition for consideration for employment and if hired, a condition of continued employment.

I understand and agree that if offered employment by Your Neighborhood Credit Union, I may be required to disclose military service information in accordance with law, and that any such employment offer shall be dependent upon the receipt of a satisfactory military record as determined by “CU Name Abbreviation”.

If hired, I agree not to disclose or use confidential information belonging to prior employers and that I will inform Your Neighborhood Credit Union of any agreements that would limit my ability to work for Your Neighborhood Credit Union.

I understand and agree that all of the foregoing terms and conditions will become part of my employment relationship with Your Neighborhood Credit Union, if I am employed by Your Neighborhood Credit Union.